CMS-10621 Payer Initiated Submission Form

1

CMS Quality Payment Program
Submission Form for Other Payer Requests for Other Payer Advanced APM
Determinations (Payer Initiated Submission Form)

Welcome to the QPP All-Payer Submission Form.
Purpose
The Payer Initiated Submission Form (Form) may be used to request that CMS determine
whether such payment arrangements are Other Payer Advanced APMs under the Quality
Payment Program as set forth in 42 CFR § 414.1420. This process is called the Payer Initiated
Other Payer Advanced APM Determination Process (Payer Initiated Process). More information
about the Quality Payment Program is available at http://qpp.cms.gov/.
[Title XIX only]
Payment arrangement determination requests for all Medicaid payment models (including
Medicaid FFS and Medicaid Managed Care Plans) may only be submitted by State Medicaid
Agencies. State Medicaid agencies requesting a determination for any payment arrangement
under Title XIX of the Social Security Act, including payment arrangements aligned with a CMS
Multi-Payer Model, must submit this Form by April 1 of the year prior to relevant QP
Performance Period.
[Medicare Health Plans only]
Medicare Health Plans requesting a determination for a payment arrangement, including one
aligned with a CMS Multi-Payer Model, must submit this Form by the annual Medicare
Advantage bid submission deadline of the year prior to relevant All-Payer QP Performance
Period. Commercial or other private payers requesting a determination for a payment
arrangement aligned with a CMS Multi-Payer Model must submit this Form by June 1 of the
year prior to relevant All-Payer QP Performance Period.
[All submitters]
CMS will not review Forms submitted after the applicable Submission Deadline.
Different payment arrangements under the same [payer/state] must be submitted separately.
[Payers/States] must submit the required information pertaining to each payment arrangement
they wish to have reviewed.

Additional Information
CMS will review the payment arrangement information in this Form to determine whether the
payment arrangement meets the Other Payer Advanced Alternative Payment Model (APM)
criteria. If a [payer/state] submits incomplete information and/or more information is required to

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make a determination, CMS will notify the [payer/state] and request the additional information
that is needed. [Payers/States] must return the requested information no later than 15 business
days from the notification date. If the [payer/state] does not submit sufficient information within
this time period, CMS will not make a determination regarding the payment arrangement. As a
result, the payment arrangement would not be considered an Other Payer Advanced APM for the
year. These determinations are final and not subject to reconsideration.
Notification
CMS will notify the [payer/state] regarding determinations as soon as practicable after applicable
Submission Deadline. CMS will also post a list of all the payment arrangements determined to be
Other Payer Advanced APMs on a CMS website.

NOTE: Please be sure to save your work before navigating away from each page as any unsaved
work will be lost. Additionally, the application times out after 30 minutes of inactivity.
A separate submission must be completed for each payment arrangement the [payer/state] is
submitting.
Helpful Links:
- QPP All-Payer Submission Form User Guide
- QPP All-Payer FAQs
- Glossary
All Forms must be completed and submitted electronically. Additional information for
submission by payer type will be disseminated following publication of the CY 2018 Quality
Payment Program Final Rule. Note that, if the submission mechanism for a given payer type,
such as the Health Plan Management System (HPMS), already collects the data points listed in a
section of the Submission Form, CMS will make reasonable efforts to ensure that there is no
need for the payer to duplicate the entry of such data.
This Form contains the following sections:
Section 1: Payer Identifying Information
Section 2: Payment Arrangement Information
Section 2.1: Title XIX (Medicaid)
Section 2.2: Medicare Health Plans
Section 2.3: Commercial or Private Payer in a CMS Multi-Payer Model
Section 3: Supporting Documentation
Section 4: Certification Statement
Payers will complete all four sections, but will only complete the subsection in Section 2 that
applies to their payer type. For example, a Medicaid Managed Care Plan will complete Section
2.1, but not Sections 2.2 or 2.3.

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All required supporting documentation must be uploaded as attachments in the Supporting
Documentation section of the Form.

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SECTION 1: Payer Identifying Information
Medicare Health Plans will complete this Form through the Health Plan Management System
(HPMS). When available, Payer Identifying Information will pre-populate for payers that
already have HPMS accounts.
A.

Payer Type
1. Select one of the following: [DROP DOWN LIST]
-

-

B.

State Medicaid Program
Medicare Health Plan (including Local Coordinated Care Plans, Regional
Coordinated Care Plans, Medicare Private Fee-for-Service Plans, Medicare Medical
Savings Account Plans, Medicare-Medicaid Plans, 1876 and 1833 Cost Plans, and
Programs of All Inclusive Care for the Elderly (PACE) plans)
Other Commercial or Private Payer in a CMS Multi-Payer Model

Payer Contact Information
1. Non-Medicaid:
Legal Entity Name: _______________
DBA Name (if applicable): __________________
Parent Company or Organization (if applicable): ________________
2. Medicaid:
- State Medicaid Agency Name
- State Medicaid Director First Name
- State Medicaid Director Last Name
.
3. All Payers:
- Business Phone Number - Ext._
Fax Number: ____________
Address Line 1 (Street Name and Number): ______
Address Line 2 (Suite, Room, etc.): ___________
City: ______ State: _____ Zip Code +4: ____________
E-mail Address: _______________
Confirm Email Address: ________________

C.

Contact Person

If questions arise during the processing of this request, CMS or its contractor will contact the
individual shown below.

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1. Is the contact person the State Medicaid Director? [Y/N]
If yes, skip to Section 2.
2. Contact Information:
First Name: ____ Last Name: ______
Telephone Number: ____ Ext:___ Fax Number: ____________
Address Line 1 (Street Name and Number): ______
Address Line 2 (Suite, Room, etc.): ___________
City: ______ State: _____ Zip Code +4: ____________
E-mail Address: _______________
Confirm Email Address: _______________
D.
- Are you submitting a form for an Other Payer Advanced APM?
Yes

No

SECTION 2: Payment Arrangement Information
SECTION 2.1: Title XIX (Medicaid)
This section includes payment arrangements that the State uses in Medicaid Fee-For-Service,
payment arrangements the State requires Medicaid managed care plans to effectuate, and
payment arrangements that Medicaid managed care plans and providers voluntarily enter
without State involvement.
A. Payment Arrangement Documentation
Please attach documentation that supports responses to the questions asked in Sections D (CMS
Medicaid Medical Home Model Determination) and E (Information for Other Payer Advanced
APM Determination) of this Form. Supporting documents may include contracts or excerpts of
contracts between Medicaid managed care plans and providers, contracts or excerpts of contracts
between Medicaid managed care plans and the State, contracts or excerpts of contracts between
the State Medicaid agency and providers, or alternative comparable documentation that supports
responses to the questions asked in Sections D and E below.

Note: Please upload all documents that you will reference when completing this submission. All
sections of this form require documentation to verify the information provided in those sections.
Documentation that will be referenced in any and all sections should be uploaded here.
1. Is information about this payment arrangement included in a State Plan Amendment (SPA),
Section 1115 demonstration waiver application, Special Terms and Conditions document,
implementation protocol document, or other document describing the 1115 demonstration

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arrangement approved by CMS? If so, please paste a link to the location of the document here
or upload with other pertinent information [Y/N]

If yes, please attach the relevant documentation. Note the document name and page
number(s) that contain information regarding this payment arrangement [TEXT BOX]
2. ]
B.

Payment Arrangement Information
1. Payment Arrangement Name (e.g. Coordinated Care ACO Model), , or terminology used
to refer to the payment arrangement: [TEXT BOX]
2. Who participates in this payment arrangement (e.g. primary care physicians, specialty
group practices, etc.)? . [TEXT BOX]
3. Is this payment arrangement open to all provider types or limited to certain specialties?
[SELECT ONE]
If the payment arrangement is limited to certain specialties, select the provider
specialties that may participate in the payment arrangement. [DROP-DOWN]
4. Select the QP Performance Period for which this payment arrangement determination is
being requested. [YEAR DROP-DOWN]
5. Payment arrangement documentation is required to support the answers provided above.
Please note the attached document(s) and page number(s) that contain this information.
[TEXT BOX]

C. Availability of Payment Arrangement
1. Locations where this Payment Arrangement will be available:
- States [DROP DOWN LIST]
- [Medicaid Only] Counties, if not statewide [DROP DOWN LIST]
2. [Medicaid Only] Is this payment arrangement available through:
- Medicaid Fee-For-Service
- Medicaid Manage Care Plan
3. - [Commercial and Medicare Health Plans only] Is this payment arrangement available
through other lines of business?
- Yes
- No

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D. Information for CMS Medicaid Medical Home Model Determination
Medicaid Medical Home Model means a payment arrangement under title XIX that CMS determines
by the following characteristics.

1. Does the payer request that CMS make a determination regarding whether this payment
arrangement is a Medicaid Medical Home Model as defined in 42 CFR 414.1305? [Y/N]
If no, skip to section E.
[If yes] List the attached document(s) and page numbers that provide evidence of the
information required in this section.. [TEXT BOX]
2. For which eligible clinicians with a primary care focus does the payment arrangement
include specific design elements? Select all Physician Specialty Codes that apply: 01
General Practice; 08 Family Medicine; 11 Internal Medicine; 16 Obstetrics and
Gynecology; 37 Pediatric Medicine; 38 Geriatric Medicine; 50 Nurse Practitioner; 89
Clinical Nurse Specialist; and 97 Physician Assistant. [CHECK BOX]
3. Does the payment arrangement require empanelment (assigning individual patients to
individual providers) of each patient to a primary clinician? [Y/N]
4. Select all elements from the following list that are required by the payment arrangement.
-

Planned coordination of chronic and preventive care. [Y/N] If yes, cite supporting
documentation and page numbers. [TEXT BOX]
Patient access and continuity of care. [Y/N] If yes, [TEXT BOX]
Risk-stratified care management. [Y/N] If yes, [TEXT BOX]
Coordination of care across the medical neighborhood. [Y/N] If yes, [TEXT BOX]
Patient and caregiver engagement. [Y/N] If yes, [TEXT BOX]
Shared decision-making. [Y/N] If yes, [TEXT BOX]
Payment arrangements in addition to, or substituting for, fee-for-service payments
(e.g. shared savings or population-based payments). [Y/N] If yes, [TEXT BOX]

Medicaid Medical Home Model Financial Risk Standard

1. Does the Medicaid Medical Home Model require that, based on the APM Entity's failure
to meet or exceed one or more specified performance standards, at least one of the
following occurs:



• -- Payer withholds payment of services to the APM Entity and/or the APM Entity’s
eligible clinicians
• -- Payer requires direct payments by the APM Entity to the payer

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



• -- Payer reduces payment rates to APM Entity and/or the APM Entity’s eligible
clinicians
• -- Payer requires the APM Entity to lose the right to all or part of an otherwise
guaranteed payment or payments
Yes/No

2. Which of the following actions does the payer take in cases where the APM Entity's fails
to meet or exceed one or more specified performance standards? [CHECK BOX]
- Payer withholds payment of services to the APM Entity and/or the APM Entity’s
eligible clinicians.
- Payer reduces payment rates to APM Entity and/or the APM Entity’s eligible
clinicians.
- Payer requires direct payments by the APM Entity to the payer.
- Payer requires the APM Entity to lose the right to all or part of an otherwise
guaranteed payment or payments.
Please describe the action(s) checked above that are taken by the payer in cases where
the APM Entity fails to meet or exceed one or more specified performance standards.
[TEXT BOX]
Please describe how the amount that an APM entity owes or forgoes is calculated. [text
box]

3. List the attached document(s) and page numbers that provide evidence of the information
required in this section.
Medicaid Medical Home Model Nominal Amount Standard

1. Is the total amount an APM Entity potentially owes or foregoes under the payment
arrangement at least 3 percent of the APM Entity’s total revenue under the payer. [Y/N]
If yes, please describe how the amount that an APM entity owes or foregoes is calculated.
[TEXT BOX]
2. List the attached document(s) and page numbers that provide evidence of the information
required in this section. [Text box]

E. Information for Other Payer Advanced APM Determination
Certified Electronic Health Record Technology (CEHRT)

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1. Does the payment arrangement require at least 50 percent of participating eligible
clinicians in each APM Entity (or each hospital if hospitals are the APM participants) to
use CEHRT as defined in 42 CFR 414.1305 to document and communicate clinical care,
as required by 42 CFR 414.1420(b)? [Y/N]
For purposes of this Form, the APM Entity is the practitioner or group of practitioners
that participates in the payment arrangement.

2. List the attached document(s) and page numbers that provide evidence of the
information required in this section.
Quality Measure Use

1. Does the payment arrangement tie payments to one or more quality measures, at least one
of which meets one or more of the following criteria: [Y/N]
- Any of the quality measures included on the proposed annual list of MIPS quality
measures;
- Quality measures that are endorsed by a consensus-based entity;
- Quality measures developed under section 1848(s) of the Act;
- Quality measures submitted in response to the MIPS Call for Quality Measures under
section 1848(q)(2)(D)(ii) of the Act or
- Any other quality measures that CMS determines to have an evidence-based focus
and are reliable and valid. (If so, please upload supporting documentation below)
If the arrangement utilizes any other quality measures, please submit here for CMS to
determine if they have an evidence-based focus and are reliable and valid.
Please upload a document using "Upload Document" or provide measure information in
the text box below. [Upload document button and text box]
2. Does the arrangement tie payments to one or more quality measures that is an outcome
measure?
- Yes
- No
[Button] Add Measure

-

A. Measure title [Text box]
B. Is the measure an outcome measure? [y/n]
o If no, check here if no outcomes measures that are relevant to this payment
arrangement are available on the MIPS quality measure list. [CHECK BOX]

10

-

C. Describe how the measure has an evidence-based focus, is reliable and valid, by
meeting one the following criteria:
i.
ii.
iii.
iv.
v.

vi.

Any of the quality measures included on the proposed annual list of MIPS
quality measures;
Quality measures that are endorsed by a consensus-based entity;
Quality measures developed under section 1848(s) of the Act;
Quality measures submitted in response to the MIPS Call for Quality
Measures under section 1848(q)(2)(D)(ii) of the Act or
Any other quality measures that CMS determines to have an evidence-based
focus and are reliable and valid
Cite the scientific evidence and/or clinical practice guidelines that support
the use of the measure in order for CMS to make a determination about the
evidence base for this measure. [Text box]
This is an outcomes measure that does not meet any of the above criteria
[Checkbox]
Describe how the measure has an evidence-based focus, is reliable and
valid, by meeting criteria selected above. [Text box]

-

D. National Quality Forum (NQF) number (if applicable) [Text box]
E. MIPS measure identification number (if applicable) [Text box]

Generally Applicable Financial Risk Standard
Section not applicable for Medicaid Medical Home Models
1. Does the payment arrangement require the participating APM Entity to bear financial risk
if actual aggregate expenditures exceed expected aggregate expenditures (i.e. benchmark
amount)? [Y/N]
2. If yes, which of the following actions does the payer take in cases where actual aggregate
expenditures exceed expected aggregate expenditures? [CHECK BOX]
- Payer withholds payment of services to the APM Entity and/or the APM Entity’s
eligible clinicians.
- Payer reduces payment rates to APM Entity and/or the APM Entity’s eligible
clinicians.
- Payer requires direct payments by the APM Entity to the payer.
Please describe the action(s) checked above that are taken by the payer in cases where
actual aggregate expenditures exceed expected aggregate expenditures. [TEXT BOX]

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3. Is this payment arrangement a capitation arrangement? [Y/N]
For purposes of Other Payer Advanced APM determination, a capitation arrangement
for purposes of Other Payer Advanced APM determinations is a payment arrangement in
which a per capita or otherwise predetermined payment is made under the payment
arrangement for all items and services for which payment is made through the payment
arrangement furnished to a population of beneficiaries, and no settlement is performed
for reconciling or sharing losses incurred or savings earned.
If yes, describe how this payment arrangement is a capitation arrangement. [TEXT BOX]
4. List the attached document(s) and page numbers that provide evidence of the information
required in this section.
Generally Applicable Nominal Amount Standard
Section not applicable for Medicaid Medical Home Models.
1. Please briefly describe the payment arrangement’s risk methodology. Note the risk
rate(s), expenditures that are included in risk calculations, circumstances under which an
APM Entity is required to repay or forego payment, and any other key components of the
risk methodology. [TEXT BOX]
2. Is the marginal risk an APM Entity potentially owes or foregoes under the payment
arrangement at least 30 percent? [Y/N]
If yes, please describe the marginal risk rate(s) and the actions required (e.g., repayment
or forfeit of future payment) under the payment arrangement. [TEXT BOX]
3. Is the minimum loss rate with which an APM Entity operates under the payment
arrangement no more than 4 percent? [Y/N]
If yes, please describe the minimum loss rate. [TEXT BOX]
4. Is the total amount an APM Entity potentially owes or foregoes under the payment
arrangement at least:
- 8 percent of the total revenue from the payer of providers and suppliers participating
in each APM Entity in the payment arrangement if financial risk is expressly defined
in terms of revenue [Y/N]
If yes, please explain how risk is expressly defined in terms of revenue. [TEXT BOX]
-

3 percent of the expected expenditures for which an APM Entity is responsible under
the payment arrangement? [CHECK BOX]
If yes, please describe how the amount that an APM Entity owes or foregoes is
calculated. [TEXT BOX]

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5.

List the attached document(s) and page numbers that provide evidence of the
information required in this section.

SECTION 2.2: Medicare Health Plans
This section is applicable for Medicare Health Plans, including: Medicare Advantage,
Medicare-Medicaid Plans, 1876 and 1833 Cost Plans, and Programs of All Inclusive Care for
the Elderly (PACE) plans.
A.

General Information

CMS will collect this information through HPMS.
1. Please select the type of Medicare Health Plan that includes this payment arrangement.
[DROP-DOWN]
2. Payment Arrangement Name (e.g. [Payer Name] Oncology Care Model), or terminology
used to refer to the payment arrangement: [TEXT BOX]
3. Who participates in this payment arrangement (e.g. primary care physicians, specialty
group practices, etc.)? [TEXT BOX]
4. Is this payment arrangement open to all provider types or limited to certain specialties?
[SELECT ONE]
If the payment arrangement is limited to certain specialties, select the provider
specialties that may participate in the payment arrangement. [DROP-DOWN]
5. Select the QP Performance Period for which this payment arrangement determination is
being requested. [YEAR DROP-DOWN]
6. Payment arrangement documentation is required to support the answers provided above.
Please note the attached document(s) and page number(s) that contain this information.
[TEXT BOX]

B. Availability of Payment Arrangement
CMS will collect contract service area information through HPMS.
1. Through which plans and in what locations is this payment arrangement offered?
[SELECT OR ENTER PLAN NAMES AND LOCATIONS]

C. Payment Arrangement Documentation

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Please attach documentation that supports responses to the questions asked in Section D
(Information for Other Payer Advanced APM Determination) of this Form. Supporting
documents may include contracts or excerpts of contracts between the payer and providers, or
alternative comparable documentation that supports responses to the questions asked in Section
D below.
Upload all documents to the Supporting Documentation section of this Form, and label each
document for reference throughout the Form.
D. Information for Other Payer Advanced APM Determination
Certified Electronic Health Record Technology (CEHRT)

1. Does the payment arrangement require at least 50 percent of participating eligible
clinicians in each APM Entity (or each hospital if hospitals are the APM participants) to
use CEHRT as defined in 42 CFR 414.1305 to document and communicate clinical care,
as required by 42 CFR 414.1420(b)? [Y/N]
For purposes of this Form, the APM Entity is the practitioner or group of practitioners
that participates in the payment arrangement.
2. List the attached document(s) and page numbers that contain the information required in
this section. [TEXT BOX]

Quality Measure Use

1. Does the payment arrangement tie payments to one or more quality measures, at least one
of which meets one or more of the following criteria: [Y/N]
- Any of the quality measures included on the proposed annual list of MIPS quality
measures;
- Quality measures that are endorsed by a consensus-based entity;
- Quality measures developed under section 1848(s) of the Act;
- Quality measures submitted in response to the MIPS Call for Quality Measures under
section 1848(q)(2)(D)(ii) of the Act or
- Any other quality measures that CMS determines to have an evidence-based focus
and are reliable and valid. (If so, please upload supporting documentation below)
If the arrangement utilizes any other quality measures, please submit here for CMS to
determine if they have an evidence-based focus and are reliable and valid.

14
Please upload a document using "Upload Document" or provide measure information in
the text box below. [Upload document button and text box]
2. Does the arrangement tie payments to one or more quality measures that is an outcome
measure?
- Yes
- No

-

-

A. Measure title [Text box]
B. Is the measure an outcome measure? [y/n]
o If no, check here if no outcomes measures that are relevant to this payment
arrangement are available on the MIPS quality measure list. [CHECK BOX]
C. Describe how the measure has an evidence-based focus, is reliable and valid, by
meeting one the following criteria:
i.
ii.
iii.
iv.
v.

Any of the quality measures included on the proposed annual list of MIPS
quality measures;
Quality measures that are endorsed by a consensus-based entity;
Quality measures developed under section 1848(s) of the Act;
Quality measures submitted in response to the MIPS Call for Quality
Measures under section 1848(q)(2)(D)(ii) of the Act or
Any other quality measures that CMS determines to have an evidence-based
focus and are reliable and valid

Cite the scientific evidence and/or clinical practice guidelines that support
the use of the measure in order for CMS to make a determination about the
evidence base for this measure. [Text box]
vi.

This is an outcomes measure that does not meet any of the above criteria
[Checkbox]
Describe how the measure has an evidence-based focus, is reliable and
valid, by meeting criteria selected above. [Text box]

-

D. National Quality Forum (NQF) number (if applicable) [Text box]
E. MIPS measure identification number (if applicable) [Text box]

Generally Applicable Financial Risk Standard

15
1. Does the payment arrangement require the participating APM Entity to bear financial risk
if actual aggregate expenditures exceed expected aggregate expenditures (i.e. benchmark
amount)? [Y/N]
2. If yes, which of the following actions does the payer take in cases where actual aggregate
expenditures exceed expected aggregate expenditures? [CHECK BOX]
- Payer withholds payment of services to the APM Entity and/or the APM Entity’s
eligible clinicians.
- Payer reduces payment rates to APM Entity and/or the APM Entity’s eligible
clinicians.
- Payer requires direct payments by the APM Entity to the payer.
Please describe the action(s) checked above that are taken by the payer in cases where
actual aggregate expenditures exceed expected aggregate expenditures. [TEXT BOX]
3. Is this payment arrangement a capitation arrangement? [Y/N]
For purposes of Other Payer Advanced APM determination, a capitation arrangement
for purposes of Other Payer Advanced APM determinations is a payment arrangement in
which a per capita or otherwise predetermined payment is made under the payment
arrangement for all items and services for which payment is made through the payment
arrangement furnished to a population of beneficiaries, and no settlement is performed
for reconciling or sharing losses incurred or savings earned.
If yes, describe how this payment arrangement is a capitation arrangement. [TEXT BOX]

Generally Applicable Nominal Amount Standard
1. Please briefly describe the payment arrangement’s risk methodology. Note the risk
rate(s), expenditures that are included in risk calculations, circumstances under which an
APM Entity is required to repay or forego payment, and any other key components of the
risk methodology. [TEXT BOX]
2. Is the marginal risk an APM Entity potentially owes or foregoes under the payment
arrangement at least 30 percent? [Y/N]
If yes, please describe the marginal risk rate(s) and the actions required (e.g., repayment
or forfeit of future payment) under the payment arrangement. [TEXT BOX]
3. Is the minimum loss rate with which an APM Entity operates under the payment
arrangement no more than 4 percent? [Y/N]
If yes, please describe the minimum loss rate. [TEXT BOX]
4. Is the total amount an APM Entity potentially owes or foregoes under the payment
arrangement at least:

16
-

8 percent of the total revenue from the payer of providers and suppliers participating
in each APM Entity in the payment arrangement if financial risk is expressly defined
in terms of revenue [Y/N]
If yes, please explain how risk is expressly defined in terms of revenue. [TEXT BOX]

-

3 percent of the expected expenditures for which an APM Entity is responsible under
the payment arrangement? [CHECK BOX]
If yes, please describe how the amount that an APM Entity owes or foregoes is
calculated. [TEXT BOX]

SECTION 2.3: Commercial or Private Payer in a CMS Multi-Payer Model
A.

General Information
1. Select the CMS Multi-Payer Model: [DROP DOWN LIST]
2. Payment Arrangement Name (e.g. [Payer Name] Oncology Care Model), or terminology
used to refer to the payment arrangement: [TEXT BOX]
3. Who participates in this payment arrangement (e.g. primary care physicians, specialty
group practices, etc.)? [TEXT BOX]
4. Is this payment arrangement open to all provider types or limited to certain specialties?
[SELECT ONE]
If the payment arrangement is limited to certain specialties, select the provider
specialties that may participate in the payment arrangement. [DROP-DOWN]
5. Select the QP Performance Period for which this payment arrangement determination is
being requested. : [YEAR DROP-DOWN]
6. Payment arrangement documentation is required to support the answers provided above.
Please note the attached document(s) and page number(s) that contain this information.
[TEXT BOX]

B. Availability of Payment Arrangement
1. Select locations where this payment arrangement will be available:
- States [DROP DOWN LIST]
2. Is this payment arrangement available through other lines of business? [
C. Payment Arrangement Documentation

17
Please attach documentation that supports responses to the questions asked in Section D
(Information for Other Payer Advanced APM Determination) of this Form. Supporting
documents may include contracts or excerpts of contracts between the payer and providers, or
alternative comparable documentation that supports responses to the questions asked in Section
D below.
Upload all documents to the Supporting Documentation section of this Form, and label each
document for reference throughout the Form.

Note: Please upload all documents that you will reference when completing this submission. All
sections of this form require documentation to verify the information provided in those sections.
Documentation that will be referenced in any and all sections should be uploaded here.

D. Information for Other Payer Advanced APM Determination
Certified Electronic Health Record Technology (CEHRT)

1. Does the payment arrangement require at least 50 percent of participating eligible
clinicians in each APM Entity (or each hospital if hospitals are the APM participants) to
use CEHRT as defined in 42 CFR 414.1305 to document and communicate clinical care,
as required by 42 CFR 414.1420(b)? [Y/N]
For purposes of this Form, the APM Entity is the practitioner or group of practitioners
that participates in the payment arrangement.
2. List the attached document(s) and page numbers that provide evidence of the
information required in this section.

Quality Measure Use

1. Does the payment arrangement tie payments to one or more quality measures, at least one
of which meets one or more of the following criteria: [Y/N]
- Any of the quality measures included on the proposed annual list of MIPS quality
measures;
- Quality measures that are endorsed by a consensus-based entity;
- Quality measures developed under section 1848(s) of the Act;
- Quality measures submitted in response to the MIPS Call for Quality Measures under
section 1848(q)(2)(D)(ii) of the Act or
- Any other quality measures that CMS determines to have an evidence-based focus
and are reliable and valid. (If so, please upload supporting documentation below)

18
If the arrangement utilizes any other quality measures, please submit here for CMS to
determine if they have an evidence-based focus and are reliable and valid.
Please upload a document using "Upload Document" or provide measure information in
the text box below.
2. Does the arrangement tie payments to one or more quality measures that is an outcome
measure?
- Yes
- No
Add Measure [“Add Measure” may be used as many times as the submitter wishes]

-

A. Measure title [Text box]
B. Is the measure an outcome measure? [y/n]
o If no, check here if no outcomes measures that are relevant to this payment
arrangement are available on the MIPS quality measure list. [CHECK BOX]

-

C. Describe how the measure has an evidence-based focus, is reliable and valid, by
meeting one the following criteria:
[Checkboxes]
i.
Any of the quality measures included on the proposed annual list of MIPS
quality measures;
ii. Quality measures that are endorsed by a consensus-based entity;
iii. Quality measures developed under section 1848(s) of the Act;
iv. Quality measures submitted in response to the MIPS Call for Quality
Measures under section 1848(q)(2)(D)(ii) of the Act or
v.
Any other quality measures that CMS determines to have an evidence-based
focus and are reliable and valid
Cite the scientific evidence and/or clinical practice guidelines that support
the use of the measure in order for CMS to make a determination about the
evidence base for this measure. [Text box]
vi.

This is an outcomes measure that does not meet any of the above criteria
[Checkbox]
Describe how the measure has an evidence-based focus, is reliable and
valid, by meeting criteria selected above. [Text box]

-

D. National Quality Forum (NQF) number (if applicable) [Text box]
E. MIPS measure identification number (if applicable) [Text box]

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Generally Applicable Financial Risk Standard

1. Does the payment arrangement require the participating APM Entity to bear financial risk
if actual aggregate expenditures exceed expected aggregate expenditures (i.e. benchmark
amount)? [Y/N]
2. If yes, which of the following actions does the payer take in cases where actual aggregate
expenditures exceed expected aggregate expenditures? [CHECK BOX]
- Payer withholds payment of services to the APM Entity and/or the APM Entity’s
eligible clinicians.
- Payer reduces payment rates to APM Entity and/or the APM Entity’s eligible
clinicians.
- Payer requires direct payments by the APM Entity to the payer.
Please describe the action(s) checked above that are taken by the payer in cases where
actual aggregate expenditures exceed expected aggregate expenditures. [TEXT BOX]
3. Is this payment arrangement a capitation arrangement? [Y/N]
For purposes of Other Payer Advanced APM determination, a capitation arrangement
for purposes of Other Payer Advanced APM determinations is a payment arrangement in
which a per capita or otherwise predetermined payment is made under the payment
arrangement for all items and services for which payment is made through the payment
arrangement furnished to a population of beneficiaries, and no settlement is performed
for reconciling or sharing losses incurred or savings earned.
If yes, describe how this payment arrangement is a capitation arrangement. [TEXT BOX]
4. List the attached document(s) and page numbers that provide evidence of the information
required in this section.
Generally Applicable Nominal Amount Standard
1. Please briefly describe the payment arrangement’s risk methodology. Note the risk
rate(s), expenditures that are included in risk calculations, circumstances under which an
APM Entity is required to repay or forego payment, and any other key components of the
risk methodology. [TEXT BOX]
2. Is the marginal risk an APM Entity potentially owes or foregoes under the payment
arrangement at least 30 percent? [Y/N]
If yes, please describe the marginal risk rate(s) and the actions required (e.g., repayment
or forfeit of future payment) under the payment arrangement. [TEXT BOX]

20
3. Is the minimum loss rate with which an APM Entity operates under the payment
arrangement no more than 4 percent? [Y/N]
If yes, please describe the minimum loss rate. [TEXT BOX]
4. Is the total amount an APM Entity potentially owes or foregoes under the payment
arrangement at least:
- 8 percent of the total revenue from the payer of providers and suppliers participating
in each APM Entity in the payment arrangement if financial risk is expressly defined
in terms of revenue [Y/N]
If yes, please explain how risk is expressly defined in terms of revenue. [TEXT BOX]
-

3 percent of the expected expenditures for which an APM Entity is responsible under
the payment arrangement? [CHECK BOX]
If yes, please describe how the amount that an APM Entity owes or foregoes is
calculated. [TEXT BOX]

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SECTION 4: Certification Statement
I have read the contents of this submission. By submitting this Form, I certify that I am legally
authorized to bind the payer. I further certify that the information contained herein is true,
accurate, and complete, and I authorize the Centers for Medicare & Medicaid Services (CMS) to
verify this information. If I become aware that any information in this Form is not true, accurate,
or complete, I will notify CMS of this fact immediately. I understand that the knowing omission,
misrepresentation, or falsification of any information contained in this document or in any
communication supplying information to CMS may be punished by criminal, civil, or
administrative penalties, including fines, civil damages and/or imprisonment.
I agree [Check box]
[AUTHORIZED INDIVIDUAL NAME, TITLE, PAYER NAME]

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Payer Initiated Submission Form Privacy Act Statement
The Centers for Medicare & Medicaid Services (CMS) is authorized to collect the information
requested on this Form by sections 1833(z)(2)(B)(ii) and (z)(2)(C)(ii) of the Social Security Act
(42 U.S.C. 1395l).
The purpose of collecting this information is to determine whether the submitted payment
arrangement is an Other Payer Advanced APM as set forth in 42 C.F.R. 414.1420 for the
relevant All-Payer QP Performance Period.
The information in this request will be disclosed according to the routine uses described below.
Information from these systems may be disclosed under specific circumstances to:
1. CMS contractors to carry out Medicare functions, collating or analyzing data, or to detect
fraud and abuse;
2. A congressional office in response to a subpoena;
3. To the Department of Justice or an adjudicative body when the agency, an agency
employee, or the United States Government is party to litigation and the use of the
information is compatible with the purpose for which the agency collected the
information;
4. To the Department of Justice for investigating and prosecuting violations of the Social
Security Act, to which criminal penalties are attached.
Protection of Proprietary Information
Privileged or confidential commercial or financial information collected in this Form is protected
from public disclosure by Federal law 5 U.S.C. 552(b)(4) and Executive Order 12600.
Protection of Confidential Commercial and/or Sensitive Personal Information
If any information within this request (or attachments thereto) constitutes a trade secret or
privileged or confidential information (as such terms are interpreted under the Freedom of
Information Act and applicable case law), or is of a highly sensitive personal nature such that
disclosure would constitute a clearly unwarranted invasion of the personal privacy of one or
more persons, then such information will be protected from release by CMS under 5 U.S.C.
552(b)(4) and/or (b)(6), respectively.
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0938-1314 (Expires XX/XX/XXXX). The
time required to complete this information collection is estimated to average [Insert Time
(hours or minutes)] per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this
form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer,
Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do

23
not send applications, claims, payments, medical records or any documents containing
sensitive information to the PRA Reports Clearance Office. Please note that any
correspondence not pertaining to the information collection burden approved under the
associated OMB control number listed on this form will not be reviewed, forwarded, or
retained. If you have questions or concerns regarding where to submit your documents,
please contact [Benjamin Chin 410-786-0679].